<div style="display:block;background-color:#FFF">
  <a href="#" onclick ="$('#demographics_page').dialog('close')" data-role="button" data-inline="true" data-icon="back">Back</a>
  <a href="#mainpage" onclick ="changeDemographics()" rel="external" data-role="button" data-inline="true" data-theme="b" data-icon="check">Submit</a>

<br/>
<label for="age" class="ui-input-text">Age:</label>
<select name="age" id="age" data-native-menu='false'>
<option value="Not"> -- Not Selected -- </option>
<option value="0-2" >0-2 Yr</option>
<option value="3-5" >3-5 Yr</option>
<option value="6-12">6-12 Yr</option>
<option value="13-20">13-20 Yr</option>
<option value="21-35">21-35 Yr</option>
<option value="36-50">36-50 Yr</option>
<option value="51-65">51-65 Yr</option>
<option value="66-80">66-80 Yr</option>
<option value="81+">81+ Yr</option>
</select>

<label for="gender" class="ui-input-text">Gender:</label>
<select name="gender" id="gender" data-native-menu='false'>
<option value="Not"> -- Not Selected -- </option>
<option value="Male" >Male</option>
<option value="Female" >Female</option>
<option value="Trans">Uncertain/Indetermined</option>
</select>

<fieldset data-role="controlgroup" data-type="horizontal">
<legend>I have seen this Patient before:</legend>
<input type="radio" name="radio" id="Yes" value="Yes"/>
<label for="Yes" id="yes1">Yes</label>

<input type="radio" name="radio" id="No" value="No" checked="checked"  />
<label for="No" id="no1">No</label>
</fieldset>

<br/>
  <a href="#" onclick ="$('#demographics_page').dialog('close')" data-role="button" data-inline="true" data-icon="back">Back</a>
  <a href="#mainpage" onclick ="changeDemographics()" rel="external" data-role="button" data-inline="true" data-theme="b" data-icon="check">Submit</a>


</div>